Alcoholism and Alcohol Liver Disease from a Transplant Hepatology Perspective

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1 Alcoholism and Alcohol Liver Disease from a Transplant Hepatology Perspective Clark Kulig, MD Director, Porter Center for Liver Care Denver, CO February 2015

2 Does quantity of alcohol correlate with liver disease? How can problematic drinking be detected? Moral Issue vs. Disease? Should alcoholics receive liver transplantation?

3 Objectives Outline the behavioral diagnoses associated with alcohol use Understand the types of alcohol liver disease Summarize therapeutic options for alcohol liver disease

4 Alcohol Hath Drowned More Men than the Sea Two-thirds of Americans drink alcohol 10% of Americans (10 million people) abuse alcohol 12-18% lifetime prevalence of alcohol abuse or dependence #2 (with HCV) and #3 indication for liver transplantation Vaillant G, Natural History of Alcoholism,

5 Behavioral Alcohol Diagnoses Alcohol Use Alcohol Abuse Alcohol Dependence

6 Alcohol Dependence = Alcoholism Behavioral Criteria Drinking despite negative consequences Health, Legal, Social Relationships, Occupation Loss of Control Physical Criteria Withdrawal Tolerance Alcohol Abuse 1-2 problematic issues from the criteria above Alcohol Use None of the issues noted above

7 Treatment of Alcoholism Readiness for Change? Pharmacologic Therapy Disulfiram (Antabuse) Acomprosate Naltrexone Provision of Structure Alcohol Monitoring, clinic visits Inpatient vs Outpatient Programs Psychological Therapy Cognitive Behavioral Therapy Alcoholics Anonymous Exercise Programs

8 Alcohol Liver Disease Steatosis Alcoholic Steatohepatitis Cirrhosis mild AST, ALT abdominal distention AST>ALT 2:1 jaundice platelets<12 ascites, LEE varices, HCC encephalopathy

9 Treatment of Alcohol Liver Disease Abstinence Nutrition Steroids Liver Transplantation

10 Treatment of Acute Alcohol Hepatitis Maddrey Discriminant Function (MDF) ( PT x 4.5) + bilirubin MDF Consider Prednisolone 40mg PO daily for 30 days Exclusions untreated infection renal failure GI bleeding

11 Should Alcoholics Receive Liver Transplantation? 1. High Demand for Liver Transplantation 2. Limited Supply of Organ Grafts 3. Who decides? (Society, UNOS, CMS/Insurance, Transplant Center, PCP, ER MD, ICU team) 4. Is Alcoholism Morally Blameworthy vs. Disease Process? (HCV Cirrhosis/IVDA) (Fatty Liver Disease/Bacon)

12 Alcohol Liver Disease and Liver Transplant Alcohol use common in US Only 10-15% of chronic heavy drinkers develop hepatic cirrhosis Cirrhosis often diagnosed at first hepatic decompensation Second most common indication for liver transplant, (20%) Vaillant G, Natural History of Alcoholism

13 Liver Transplant Successful in Alcohol Cirrhosis 41 patients with alcoholism transplanted , early cyclosporine era one-year survival was 73.2% three year survival was 68% 2/35 surviving >6 months returned to alcohol use Starzl T, JAMA 1988

14 Liver Transplant Successful in 99 alcoholic patients Alcohol Cirrhosis 45 received liver transplant 78 and 73% survival at 12 and 24 months survival not different from non-alcohol transplants better survival than HCV transplants 17 too well for transplant 19 medical exclusions, none survived one year 17 psych exclusions, 43% survived 18 months Lucey M and Beresford T, Gastro 1992

15 Liver Transplant Successful in Alcoholic Cirrhosis 84% one year survival 72% five year survival 23% five year survival without transplant alcoholic cirrhosis survival > HCV survival Bellamy C, Transplantation 2001

16 Alcoholics Do Well after Transplant Full integration into society is likely after liver transplant Cowling T, Ann Surg 2004

17 Six Month Rule Used by 85% of liver transplant centers, generally in setting of alcoholism UNOS/CMS minimal regulation Decision making at level of transplant center Medical literature: controversial interval Insurance companies: adopted dogma Lucey M, Liver Transplantation, July 2011

18 Six Month Rule Kumar: 73 individuals with alcoholism <6 months of abstinence 3/7 relapsed >6 months of abstience 3/45 relapsed Two smaller, retrospective, non-controlled studies (n=7, 24) Difficulty aquiring alcohol use data Kumar S, Hepatology 90 Osorio R Hepatology 94 Bird J, BMJ 90

19 Estimating Prognosis for Abstinence Favorable Factors insight into addiction social stability (job/housing/spouse) substitute activities level of self-esteem/hope rehabilitation relationship with nondrinker negative consequences (antabuse/pancreatic pain) Vaillant G, Natural History of Alcoholism

20 Estimating Prognosis for Abstinence Unfavorable Factors preexisting psychotic disorders/unstable character disorders multidrug abuse repeated and unsuccessful attempts at rehabilitation social isolation Vaillant G, Natural History of Alcoholism

21 Estimating the Prognosis for Abstinence after Liver Transplant 1. No single measure is a reliable prognosticator for future relapses into harmful drinking after transplantation. 2. With respect to admitting recent use, patients with alcoholism who are under consideration for LT have a conflict of interest. 3. Duration of abstinence is an imprecise prognostic tool. 4. Liver biopsy provides an unreliable estimate of recent alcohol use. 5. A careful evaluation by a trained addiction specialist with a special interest in transplant medicine is very helpful. Lucey M, Liver Transplantation, July 2011

22 Estimating the Prognosis for Abstinence after Liver Transplant 6. The psychosocial assessment determines lower and higher risks of relapsing into harmful drinking but does not determine the absolute risk. 7. The psychological assessment needs to be incorporated into a more comprehensive consideration of the appropriateness of liver transplant for a particular patient. 8. The severely ill patient who has been drinking recently but has other favorable prognostic indicators with respect to addiction poses a very difficult question for a transplant program. Lucey M, Liver Transplantation, July 2011

23 Porter Liver Transplant Alcohol Protocol 1. Six Month Sobriety rule used for mild/moderate chronic liver disease when alcohol dependence present 2. Alcohol Diagnosis/Prognosis Hepatology, Psychologist, Licensed Clinical Social Worker 3. Transplant Candidacy decisions via Selection Committee: Hepatology, Surgery, Psych, Social Work, Financial Coordinator, Nurse Coordinator, Dietician, Admin 4. Selection Committee makes decisions when there is severe disease with minimal abstinence

24 Objectives Outline the behavioral diagnoses associated with alcohol use Understand the types of alcohol liver disease Summarize therapeutic options for alcohol liver disease

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